Tumors and lesions are types of pathological anatomies characterized by abnormal growth of tissue resulting from the uncontrolled, progressive multiplication of cells, while serving no physiological function. Pathological anatomies can be treated with an invasive procedure, such as surgery, but this can be harmful and full of risks for the patient. A non-invasive method to treat a pathological anatomy (e.g., tumor, legion, vascular malformation, nerve disorder, etc.) is external beam radiation therapy. In one type of external beam radiation therapy, an external radiation source is used to direct a sequence of x-ray beams at a tumor site from multiple angles, with the patient positioned so the tumor lies in the path of the beam. As the angle of the radiation source changes, every beam passes through the tumor site, but passes through a different area of healthy tissue on its way to the tumor. As a result, the cumulative radiation dose at the tumor is high and the average radiation dose to healthy tissue is low.
The term “radiotherapy” refers to a radiation treatment procedure in which radiation is applied to a target region for therapeutic, rather than necrotic, purposes. The amount of radiation utilized in radiotherapy treatment sessions is typically about an order of magnitude smaller, as compared to the amount used in a radiosurgery session. Radiotherapy is typically characterized by a low dose per treatment (e.g., 100-200 centigray (cGy)), short treatment times (e.g., 10 to 30 minutes per treatment) and conventional or hyperfractionation (e.g., 30 to 45 days of treatment). For convenience, the term “radiation treatment” is used herein to mean radiosurgery and/or radiotherapy unless otherwise noted by the magnitude of the radiation.
In order to deliver a requisite dose to a targeted region, whilst minimizing exposure to healthy tissue and avoiding sensitive critical structures, a suitable treatment planning system is required. Treatment plans specify quantities such as the directions and intensities of the applied radiation beams, and the durations of the beam exposure. It is desirable that treatment plans be designed in such a way that a specified dose (required for the clinical purpose at hand) be delivered to a tumor, while avoiding an excessive dose to the surrounding healthy tissue and, in particular, to any important nearby organs. Developing an appropriate treatment planning system is especially challenging for tumors that are larger, have irregular shapes, or are close to a sensitive or critical structure.
A treatment plan may typically be generated from input parameters such as beam positions, beam orientations, beam shapes, beam intensities, and desired radiation dose constraints (that are deemed necessary by the radiologist in order to achieve a particular clinical goal). Sophisticated treatment plans may be developed using advanced modeling techniques, and state-of-the-art optimization algorithms.
Two kinds of treatment planning procedures are known: forward planning and inverse planning. In the early days of radiation treatment, treatment planning systems tended to focus on forward planning techniques. In forward treatment planning, a medical physicist determines the radiation dose duration, or beam-on time, and trajectory of a chosen beam and then calculates how much radiation will be absorbed by the tumor, critical structures (i.e., vital organs) and other healthy tissue. There is no independent control of the dose levels to the tumor and other structures for a given number of beams, because the radiation absorption in a volume of tissue is determined by the properties of the tissue and the distance of each point in the volume to the origin of the beam and the beam axis. More specifically, the medical physicist may “guess” or assign, based on his experience, values to various treatment parameters such as beam positions and beam intensities. The treatment planning system then calculates the resulting dose distribution. After reviewing the resulting dose distribution, the medical physicist may adjust the values of the treatment parameters. The system re-calculates a new resulting dose distribution. This process may be repeated, until the medical physicist is satisfied by the resulting dose distribution, as compared to his desired distribution. Forward planning tends to rely on the user's ability to iterate through various selections of beam directions and dose weights, and to properly evaluate the resulting dose distributions. The more experienced the user, the more likely that a satisfactory dose distribution will be produced.
Forward planning often utilizes an isocentric treatment process in which an external radiation source is used to direct a sequence of x-ray beams at a tumor target from multiple angles, with the patient being positioned so the tumor is at the center of rotation (isocenter) of the beams. In isocentric planning, each available beam is targeted at the same point to form the “isocenter,” which generally may be a roughly spherical isodose region as represented by a sphere. Accordingly, isocentric planning may be often applied when treating a tumor that has a substantially regular (e.g., spherical) shape. The radiation beams are shaped by a device called a collimator. The collimator consists of dense material that is opaque to radiation, with the exception that there is a hollow portion through which radiation may pass. The shape and size of the radiation beam is then determined by the shape and size of this hollow portion (aperture). When we refer to “collimator size”, we mean the size of radiation beam created by a given collimator configuration, as measured at a given distance from the radiation source. Hence the size of the sphere of radiation dose in isocentric planning may depend on the collimator size which may be, for example, about 30 millimeters as measured at about 800 millimeters from the radiation source. As the angle of the radiation source is changed, every beam passes through the tumor, but may pass through a different area of healthy tissue on its way to the tumor. To treat a target pathological anatomy, multiple dose spheres are superimposed or “stacked” on each other in an attempt to obtain a contour that closely matches the silhouette of the pathological anatomy. By stacking isocenters within a target volume, a plan may be developed that ensures that nearly all the target receives a sufficient dose. As a result, the cumulative radiation dose at the tumor may be high and the average radiation dose to healthy tissue may be low.
In gantry-based radiation treatment systems, the radiation beam may be shaped by a multileaf collimator (MLC), to conform to the silhouette of the target as seen from the orientation of the radiation beam source. The MLC is mounted on a gantry and coupled to a linear accelerator. The MLC includes several adjustable leaves which are able to block and/or filter radiation to vary the beam intensity and control distribution of the radiation. The leaves are typically made of a dense material (e.g., tungsten) that is essentially opaque to radiation, and are mechanically driven, individually, in and out of the radiation field of the beam to create a radiation field shape. FIG. 1 shows the leaves of an MLC adjusted to create a radiation field shape corresponding to a target silhouette. There are two conventional ways in which radiation treatment plans are generated for MLCs.
Most radiation delivery systems make use of a circular gantry surrounding the patient with a linear accelerator free to rotate within the circle. Multiple beams may be produced moving the accelerator around the circle; the trajectory of the beam can be characterized by a single angle describing the angle of rotation, called the “gantry angle”. With conventional IMRT (Intensity Modulated Radiation Therapy) systems having an MLC, treatment planning is performed by, first, determining an optimal dose distribution at each node of the treatment system, i.e. each desired angle. After the dose distribution has been determined, field shapes are generated using a leaf sequencing algorithm, taking into account constraints of the MLC. That is, a set of instructions is generated to move the leaves in a given pattern, in order to achieve as closely as possible the optimum dose distribution. After the predicted dose distribution is calculated from the generated leaf sequencing algorithm, the radiation treatment of the target volume of interest (“VOI”) occurs.
With conventional 3D conformal systems having an MLC, treatment planning is performed by first matching the leaves of the MLC to the target silhouette. In this case, there is no leaf sequencing algorithm, so the planning component seeks only to match the shape of each beam to the silhouette of the target from that gantry angle. Once the MLC positions have been determined, a predicted dose distribution may be generated, and the radiation treatment of the target VOI occurs.
Another mode of delivering radiation treatment is that provided by the CyberKnife® system. Instead of moving the radiation delivery device in a circle around the patient, it is mounted on a multi-jointed robotic manipulator that has freedom to make both translational and rotational movement. Hence, radiation may be delivered from a wide range of positions and orientations relative to the patient, instead of being restricted to angles chosen within the circular arc on which the gantry-mounted linac can travel.